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Emotional highs and lows are common after hysterectomy with many women experiencing tearfulness and irritability. One explanation is the stress of the surgery and the effect of the anaesthetic. In addition, the removal of the ovaries, or their inadvertent damage, will quickly lead to changes in sex hormone levels and, with this, mood fluctuations.

Hot flushes, night sweats and associated sleeplessness may follow close on the heels of a hysterectomy, particularly if the ovaries have been removed. These effects are blamed on rapid changes in the levels of oestrogen, progesterone and other sex hormones circulating in the bloodstream. The symptoms diminish over the space of months or years but they can play havoc with the lives of women and their loved ones until then. Hormone therapy is often regarded as a simple solution to these problems and in some women this appears to be the case. Others, however, cannot tolerate hormone therapy or they may be concerned about possible long-term effects, for example the increased risk of developing breast cancer with prolonged (more than five years) use of hormone therapy.

On returning home, some women expect to resume everyday activities without missing a beat. Unfortunately, pain or other problems may prevent this and partners, children and relatives should be on call to lend a hand. If this sort of help is not available, it may be possible to arrange for assistance from the local council, a nursing service or another organisation. The decision about when to resume driving is important as lives can hinge on it. Emergency braking requires quick reflexes and leg strength. By the time women are able to climb stairs quickly and do the garden, they are usually fit enough to drive.

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You are probably beginning to understand how the complex and delicate balance of our reproductive systems can be upset by things we do, eat, or come into contact with in everyday life. Of all these factors, nutrition (getting your diet right and correcting any deficiencies) is probably the most important. It’s certainly a vital first step for any couple trying to improve their fertility, even if they eventually opt for an assisted conception.

However, when you keep trying to conceive and nothing happens it is easy to get into a panic and start thinking that something is seriously wrong – either with you or your partner. I describe the various medical tests you can both have, in order to check different aspects of your fertility. These tests can highlight specific medical problems and assess crucial factors like hormone levels and sperm quality. Sometimes simply going through the process of eliminating different possibilities can give you peace of mind and make you more relaxed (which can be helpful in itself). And the information you gain may be very useful. For instance, if you find that your partner has poor sperm motility you can target the problem directly with additional nutrients like L-arginine.

Case History

Barbara was 41 when she came to see me. She had tried four IUI cycles with no success. She had been told her FSH levels were too high, ranging from 24 to 33 at the beginning of her cycles over a number of months. The cutoff level is 10 for most IVF clinics and levels as high as Barbara’s would normally indicate that she was beginning the menopause. The clinic had asked her to be tested each month to see how the FSH was fluctuating. Although the clinic was focusing on Barbara’s hormone levels, I Still suggested that both she and her partner should be tested for nutritional deficiencies and have these corrected, which they did. They both followed the Four-Month Preconception Plan and Barbara conceived naturally on a cycle with an FSH of 24. She now has a healthy baby boy.

Although it is important to investigate any possible medical problems, most couples are better advised only to start these investigations once they have implemented their preconception dietary and lifestyle changes by following the four-month plan. They should then try to conceive on their own for approximately six months. This is because many of the factors that will be tested – such as hormone levels, ovulation and sperm quality – will start to improve very quickly of their own accord, once both partners have established the recommended changes. The only exceptions to this are couples where the woman is older than 35 or couples who have reason to believe that they have a medical problem (such as the symptoms of an infection, which should be treated immediately).

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Visualization – imagery

Visualization will not get rid of your pain completely or permanently but it should give you a ‘time out’ period where you can use your imagination to create mental images that blot out your pain.

You may focus on your pain by imagining that you are in an open field on a warm sunny day. Just beside you is a helium-filled balloon with a large basket attached. You imagine that you load up the basket with all your pain and discomfort. The balloon now slowly rises up in the air and floats away, taking with it the basket loaded with your pain.

You may focus on your endometriosis by imagining that the endometriosis cells in your body are being invaded by your body’s natural defenders, an army of white blood cells. The white cells destroy the unwanted endometriosis cells and you can visualize your organs healthy once again.

These images may also focus on yourself. You may like to imagine yourself in surroundings that give you enormous pleasure. For example, you may visualize yourself on a tropical island, peacefully lying on the warm golden sands while palm trees gently sway in the breeze and the waves quietly lap onto the shore.

You may like to imagine yourself walking through a field early in the morning, the lush green grass still glistening in the sun from the morning dew. You notice the deep blue sky dotted with wispy white clouds, the golden sun sending forth its warming rays and the spring flowers showing forth a multitude of colours. You then enter a cool dark forest, which feels refreshing after the warm sun. Here you may rest a while, taking in the peace and tranquility of your surroundings, before returning to reality.

Being positive

Thoughts about pain which are negative can lead to anxiety, tension and stress and ultimately more pain.

If negative thoughts and emotions can be removed and your perception of pain is altered then your coping abilities and lifestyle improve, often leading to a significant decrease in actual pain.

You have to accept that there is no instant cure for your pain and discomfort and that you need to take steps to do something positive about dealing with it.

Pain clinics

There are pain clinics throughout Australia that specialize in the treatment and management of various types of chronic pain. Some are located at major public hospitals and others are in private practices. Some women find these clinics of enormous benefit while others do not.

The approach of pain clinics varies, but they usually have a team of specialists including anesthetists, neurologists, psychologists, physiotherapists and nurses.

They may use a single method of treatment or several treatments to help relieve pain. The treatments may include drug therapy, relaxation, group therapy, manipulation, massage, electro-stimulation, acupuncture, acupressure, hydrotherapy, and meditation.

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Teenagers are capable of having babies. There is no biological law that says you need to be a certain age, or belong to a certain group, or be married in order to produce offspring. You need a functioning reproductive system, and most of us have that within a couple of years of our first period.

Some teenage women become pregnant and have no particular problems. A young woman may have the benefit of a supportive partner or family, who can help her through the pregnancy and beyond.

However, many teenagers who are pregnant have special needs. There may be difficulties at home. A young woman may not have the support of her family or her partner. She may have financial troubles, particularly if she is still at school when she becomes pregnant. She may not want anyone to know about the pregnancy, which could prevent her from seeking medical help early. She may be concerned about her ability to care for a baby.

Fortunately there are people who can help. Some women’s hospitals have recognized the special needs of these young women, and have started young mothers’ clinics. Most other hospitals and councils have social workers, who are able to assist young women with the economic and social problems they might face. Medical and nursing staff would encourage young pregnant women to attend antenatal care early and regularly, to ensure that they and their pregnancies are progressing well. There are also support groups in some communities specifically for young mothers.

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The fact that a tablet capable of inducing abortions has been produced should not be surprising. We have developed pills and devices for preventing pregnancies, and safe efficient operations for terminating them. Yet the concept of an abortion pill has stirred a great deal of passionate debate on both sides of the fence.

Those against the idea worry (among other things) about the easy availability of abortion and that if it was done with a pill, rather than an operation, then people may take the issue less seriously, and the value of human life would suffer. There is concern about its safety and long-term effects, as with all new medications. It is currently being trialled in several centres around the world to establish its best use. Those in favour of the abortion pill argue equally vehemently, saying that if it is safe it should be available as an alternative to surgical abortion.

The pill itself is a very potent anti-progestogen, which means it acts in the opposite way to the naturally occurring progestogens, such as progesterone. If there is a pregnancy in the uterus, the action of RU486 is to oppose the normal pregnancy hormones so the pregnancy cannot continue and the products of conception are expelled. This will usually happen two to three days after taking the pill. It is usually given together with another drug, a prostaglandin, which acts to help dilate the cervix and contract the uterus. It seems that some of the side-effects, in particular some of the more serious, rare, life-threatening problems encountered so far, have been related to the prostaglandin rather than RU486.

Although studies have shown it to be effective at producing abortion, the possible problems with a pill-induced termination are similar to those of a surgical termination, such as an incomplete emptying, or an ongoing pregnancy. There can occasionally be heavy bleeding. There are no anaesthetic risks, and less risk of introducing infection, but the risks involved with the accompanying prostaglandin need to be further evaluated, it seems.

The side-effects of RU486 include nausea, vomiting, breast tenderness, and cycle disturbance.

Studies are being done to see if RU486 may have a place as a morning-after pill, like the currently used regimen of the oral contraceptive pill. It is also being trialled as a menstrual regulator, which means that it may be taken once a month, or if the period is delayed, without a pregnancy being confirmed.

RU486 is widely used in several other countries. The role of RU486 in Australia is not (at the time of writing) fully defined. When the dust settles from the inevitable bunfight that accompanies any development in reproductive medicine, it will be interesting to see how we use it, if at all.

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New drugs are being trialled all over the world, with the hope of a breakthrough in fighting this disease. In the meantime there are some treatments available. Certain drugs, such as AZT have been found to alter the rate of progression of the disease.

A person with AIDS usually suffers from infections with other bugs. These are called ‘opportunistic infections’, which means that they infect the person more easily because HIV has damaged the body’s natural immune system. That means a person who has AIDS may require antibiotics for lung infections, or creams for skin infections, etc. These treatments are not aimed at getting rid of the AIDS virus, because they can’t. They are there to treat the opportunistic infections as they arise, and are often successful until late in the disease, when the body has so few defence cells left that no amount of antibiotics can help.

Researchers are also trying to develop a vaccine against the virus, in the same way that we have vaccines against other diseases, like measles and polio. It would be a big help.

Alternative therapies, dietary manipulations and lifestyle changes may have a significant role to play in at least modifying, if not treating the disease. So far there are no hard and fast guarantees, but there are many individual stories which give hope.

People who are HIV positive, and people who have AIDS require medical treatment which at the moment is specialised. They will usually be directed to specialist clinics or doctors, and will require regular follow up and treatment.

‘Treatment’ of a person who is HIV positive, or who has AIDS should involve the whole person. It is not simply a matter of looking at the white blood cells. How a person is affected by a disease, in a physical, social and emotional sense, is very important. HIV infection, because of its nature, often has an enormous impact on the lives of people who are infected, as well as those close to them. It is important that their needs are met. Making individual help available, as well as educating the public in the realities, rather than the rumours about HIV and AIDS, may help to do this.

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The diaphragm. A close relative of the condom, the diaphragm is also a latex device, but is designed to fit over the cervix. In order to make as sperm-proof a cover as possible, the correct size must be worn. Initially a woman should be ‘fitted’ for a diaphragm by a doctor to ensure she buys the right size. A change of size may be necessary after a woman has had a baby, or pelvic surgery, or significant (more than 5 kilograms) weight change. But generally, once she has the right size diaphragm, the woman can re-use this over and over again. She should be re-fitted and buy a new diaphragm every two years as the latex can perish. The only added expense is spermicidal cream or jelly, which is recommended for use with the diaphragm (like the condom, the latex of the diaphragm is damaged by oil-based substances).

Prior to intercourse the diaphragm should be inserted, with spermicidal cream placed inside the dome. It can be inserted just before sexual activity, or in the morning of any day you are likely to have sex. The diaphragm must then be left in place for at least four hours after last having sex, before being removed and washed. If it is left in for more than twenty-four hours at a time you may notice a slightly smelly vaginal discharge.

When fitted properly the diaphragm cannot be felt by either partner. However, as with all other methods, there are those who don’t like it. According to some it is too messy, requires quite a deal of practice and motivation to be successful and, like the condom, can ‘interrupt the flow’ of events.

On the other hand, it is fairly free of side-effects, is cheap and, like the condom, can be relatively reliable in capable hands. True failure rates again depend on the user, but it is probably similar to the condom; between six and twenty pregnancies per 100 women years, with the better score going to the couples who are practised and motivated. Like periodic abstinence, diaphragms are

probably best suited to couples spacing families. If, however, a greater degree of accurate contraception is required, other methods may be more suitable.

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These connect the uterus to the ovaries, so they form the tunnel in which the egg and sperm meet, and fertilization takes place. They are about 10 centimetres long, and the end near the ovary is wider, with finger-like projections (called fimbriae), which envelop the ovary at the time of ovulation, to receive the egg. The skinny end is attached to the uterus.

Damage to the fallopian tubes can prevent eggs and sperm meeting. Damage can result from kinking and scarring, from infection, or intentional obstruction, for example when a woman has her fallopian tubes cut and tied, or clipped.

If fertilisation does take place in the tube, and the resulting “conceptus” is obstructed from moving into the uterus, the conceptus may implant and continue to grow while in the fallopian tube (called an “ectopic pregnancy”. The tube is not the most appropriate place for a developing embryo to grow. The tube will stretch for a while, but usually after eight to ten weeks

it will rupture. This can cause bleeding into the pelvis, and is a potentially life-threatening event. Fortunately, these days most ectopic pregnancies are diagnosed and treated before they rupture.

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